EFFECT OF AN ORAL HEALTH PROMOTION PROGRAM ON GASTROPLASTY PATIENTS: A RANDOMIZED CLINICAL TRIAL

ABSTRACT BACKGROUND: Bariatric surgery can cause oral health problems in individuals, such as an increase in dental caries, periodontal diseases and dental erosion, which can be avoided if oral health promotion actions are implemented. AIMS: To assess the impact of an oral health promotion program implemented among gastroplasty patients. METHODS: This randomized clinical trial involved 208 patients undergoing gastroplasty; they were divided into two groups: Intervention Group, with participation in the Oral Health Promotion Program for Bariatric Patients, or Control Group. Assessments were carried out preoperatively, and six and 12 months postoperatively. The oral conditions assessed were: dental caries, periodontal diseases, tooth wear, dental plaque, and salivary flow. Sociodemographic information was obtained through application of structured questionnaires. For data analysis, the Chi-Square, Fisher’s Exact, and Mann-Whitney tests were performed — α=5%. RESULTS: Patients in the Intervention Group, when compared to those in the Control Group, presented: fewer changes in enamel (6M: p<0.0001; 12M: p=0.001), in dentin (6M: p<0.0001; 12M: p<0.0001), moderate tooth wear (6M=0.002; 12M=0.005), gingival bleeding (6M: p<0.0001), dental calculus (6M=0.002; 12M: p=0.03), periodontal pocket 4-5 mm (6M=0.001; 12M: p=<0.0001); greater reduction in the bacterial plaque index (6M: p<0.0001; 12M: p<0.0001), and increased salivary flow (6M: p=0.019). CONCLUSIONS: The oral health promotion program had a positive impact on the prevention and control of the main problems to the oral health of the gastroplasty patients.


A QUEDA DA PRESSÃO PORTAL APÓS DESVASCULARIZAÇÃO ESOFAGOGÁSTRICA E ESPLENECTOMIA INFLUENCIA A VARIAÇÃO DO CALIBRE DAS VARIZES E AS TAXAS DE RESSANGRAMENTO NA ESQUISTOSSOMOSE NO SEGUIMENTO EM LONGO PRAZO?
Does the drop in portal pressure after esophagogastric devascularization and splenectomy variation of variceal calibers and the rebleeding rates in schistosomiasis in late follow-up?
Walter de Biase SILVA-NETO 1 , Claudemiro QUIRESE 1 , Eduardo Guimarães Horneaux de MOURA 2 , Fabricio Ferreira COELHO 3 , Paulo HERMAN 3 ABSTRACT -Background: The treatment of choice for patients with schistosomiasis with previous episode of varices is bleeding esophagogastric devascularization and splenectomy (EGDS) in association with postoperative endoscopic therapy.However, studies have shown varices recurrence especially after long-term follow-up.Aim: To assess the impact on behavior of esophageal varices and bleeding recurrence after post-operative endoscopic treatment of patients submitted to EGDS.Methods: Thirty-six patients submitted to EGDS portal pressure drop, more or less than 30%, and compared with the behavior of esophageal varices and the rate of bleeding recurrence.Results late post-operative varices caliber when compared the pre-operative data was observed despite an increase in diameter during follow-up that was controlled by endoscopic therapy.

Conclusion
variceal calibers when comparing pre-operative and early or late post-operative diameters.
The comparison between the portal pressure drop and the rebleeding rates was also not

Perspectives
The oral health promotion program prevented the main oral health problems resulting from bariatric surgery, leading to a reduction in enamel and dentin changes, gingival bleeding, dental calculus and periodontal pockets, bacterial plaque index and tooth wear, in addition to increasing salivary flow.These results highlight the importance of inserting dental surgeons into multidisciplinary teams that treat bariatric patients in order to improve their oral conditions and, consequently, promote overall health.

Central Message
Bariatric patients can be affected by oral problems, which can be prevented by an oral health promotion program.The repercussion of bariatric surgery complications on oral health has not been adequately reported in the few longitudinal studies found in the literature, which justifies the need for further research providing information to promote the oral health of these patients and healthcare protocols with educational-preventive guidelines.
Group, provided by two trained nurses, before the oral health assessments, participants were randomly allocated to the IG, through which they joined the Oral Health Promotion Program for bariatric patients (PROBARI) (n=105), or to the CG, which received only the usual care from the clinic's health team (n=103).Clinical examinations were conducted with both the examiner and the examined person sitting, under a spotlight, with the aid of a flat mouth mirror, a World Health Organization probe (Community Periodontal Index -CPI probe) 25 , and gauze.The assessments were made by a single examiner, and information was recorded by a single notetaker, on an individualized form.A total of 10% of re-examinations were carried out to calculate the Kappa agreement index and the percentage of disagreement (clinical examination).
The oral conditions and respective indices used were: dental caries (International Caries Detection and Assessment System) 10 , periodontal disease (Community Periodontal Index) 25 , tooth wear (Tooth Wear Index) adapted by Sales-Peres et al. 16 , and dental plaque 13 .Additionally, salivary flow was measured 8 .
The PROBARI comprised instructions on dietary and oral hygiene, plaque control, salivary flow stimulation, and topical applications of fluoride varnish; the educational material was prepared from studies with educational and preventive interventions in oral health for bariatric patients, based on current scientific evidence 2,6,15 .
Before the surgical procedure, the groups (CG and IG) were given a preventive kit containing a CS 5460 toothbrush and a printed leaflet on oral health care.The instructions were reinforced monthly only for the IG patients in the postsurgical period, through Teleorientation (WhatsApp messages); the first message was sent two weeks after the educational material was delivered, and the others were sent monthly until twelve months of follow-up were completed 2,9 .
The IG patients received individual instructions regarding a less acidic and sweet diet, in order to prevent dental caries and erosion; increased water intake for greater salivary flow, and not brushing immediately after vomiting, so as to have some time between ingesting acid food and brushing the teeth, in order to inhibit the process of tooth erosion due to the association with abrasion from tooth brushing 15 .
Preventive actions included control of dental plaque and application of Clinpro White Varnish (3M ESPE) 5% fluoride varnish; they were carried out in the Obesity Surgery Centers 6 months (6M) and 12 months (12M) after the surgery, among the IG patients 5 .
Figure 1 presents a summary of the guidelines and preventive actions developed in the PROBARI 2,5,21 .
The Statistical Package for Social Sciences (SPSS) version 20.0 was used; through bivariate analysis, possible associations between the study variables were verified.For comparisons between the CG and IG, non-parametric statistics were used, by means of the Mann-Whitney, Chi-Square and Fisher's Exact tests for categorical variables.The significance level adopted was 5%.

RESULTS
Of the total number of bariatric patients who began the research, assessed preoperatively (n=208), 73.5% underwent the second assessment six months postoperatively (CG, n=103; IG, n= 105), and 50% underwent the third assessment

INTRODUCTION
O besity is associated with more than 200 comorbidities, in addition to cancer, cardiovascular diseases and stroke -pathologies responsible for an increase in mortality rates worldwide 12 .Bariatric patients seek surgery to improve their life expectancy and condition, due to the negative impact that obesity and associated diseases have on their health 21,22 .
The repercussion of bariatric surgery complications on oral health has not been adequately reported in the few longitudinal studies found in the literature 20 , which justifies the need for further research providing information to promote the oral health of these patients and healthcare protocols with educational-preventive guidelines 8 .
Gastroplasty can cause nutritional deficiencies and the dumping syndrome, with nausea and vomiting, in addition to eating disorders, such as anorexia, bulimia and binge eating, which negatively affect the oral cavity 14 , causing oral problems such as periodontal disease 4 , increased dental caries 21 , dehydration and difficulty in ingesting liquids, with the consequences being hyposalivation 7 , dental erosion 14 , as well as alveolar bone loss resulting from osteoporosis, and tooth loss 23 .
Given that the determinants of oral diseases and the common risk factors for these and other chronic diseases are known 18 , oral health should be integrated into strategies aimed at promoting general health, in order to improve the living conditions of gastroplasty patients.
The alternative hypothesis of the present study is that an oral health prevention program can positively impact the oral health of bariatric patients, preventing the main oral health problems they suffer.
The objective of this randomized clinical trial was to implement and analyze the effects of an oral health promotion program among bariatric patients.A total of 208 patients eligible for bariatric surgery were divided into two groups: Intervention Group (IG) and Control Group (CG).Previously, a pilot study was carried out with 30 patients to calculate the sample size; they did not participate in the research.

METHODS
One sample was calculated for each outcome, and the one with the largest number was considered.A significance level of 5% and a test power of 80% were adopted, and so was a minimally significant clinical difference of 30%.Taking into account the possibility of losses in the longitudinal study, there was a 20% increase in the sample.
The inclusion criteria were age between 18 and 60 years 3 , signing of the Free and Informed Consent Form (FICF) and availability to attend the appointments.The exclusion criteria were the presence of edentulism and physical and/ or mental limitations.
After opening sealed opaque envelopes containing the initials IG, for Intervention Group, and CG, for Control The IG and CG groups were matched regarding sociodemographic characteristics and the type of surgery of their members (p>0.05).
Preoperatively, there was a lower bacterial plaque index (p=0.038)and lower salivary flow for the CG (p=0.003),compared to the means observed in the IG (Table 1).Six months after the surgery, a lower rate of bacterial plaque in the IG (p<0.0001), as well as a greater salivary flow (p=0.019), could be identified.At 12 months, after bariatric surgery, a statistically significant difference was observed in the salivary flow index between the groups (p=0.785).
Comparing the CG and IG groups, in relation to periodontal conditions (Table 2), there was a significant difference for all criteria of the Community Periodontal Index (CPI) in the 6-month postoperative period, with better conditions for the IG concerning gingival bleeding (p<0.0001),dental calculus (p=0.002),4-5mm pocket (p=0.001) and 6mm/+ pocket (p=0.031).In the 12-month postoperative period, there was a significant difference between the groups for presence of dental calculus (p= 0.003) and 4-5 mm pocket (p<0.0001),being favorable to IG.
Based on criteria of the International Caries Detection and Assessment System (ICDAS) index (Table 3), in the preoperative period, no statistical difference was identified between the groups for prevalence of caries.After six months, there was a lower incidence of changes in the IG, with a significant difference in relation to changes in both the enamel (p<0.0001) and dentin (p<0.0001).At 12 months, the result was again favorable to the IG, with a significant difference for changes in both the enamel (p=0.001) and dentin (p<0.0001).
In the 6-month postoperative period, with respect to the Dental Wear Index -DWI (Table 4), comparing the groups, there was a significant difference for the moderate criterion (p=0.002),being favorable to the IG.At 12 months, a lower mean for the IG could also be observed regarding the "moderate wear" criterion (p=0.005).The highest mean for severe wear was found in the CG group at 12 months, although statistical significance was not reached (p=0.092).

Dry mouth sensation:
• Stay hydrated to prevent a decrease in saliva.Saliva is important for preventing oral problems, such as caries, tooth erosion and periodontal diseases.Water is essential, so take a bottle of water with you to remember to drink in small sips; it can be flavored to make it easier to drink.• Chewing sugar-free gum helps increase salivation.Wait 2 months after surgery to use the gum.
• If your mouth is very dry, let us know; we can recommend the use of artificial saliva.

Dental caries
• Plaque is a sticky, colorless deposit of bacteria that forms on the surface of the tooth, and the sugar associated with bacterial plaque is mainly responsible for the development of this oral disease, so avoid sweets (treats).• Avoid sugary sodas and juices, create healthy habits.
• Dairy products are sources of calcium, which are essential for preventing cavities; skimmed milk and sugar-free yogurt are equally beneficial.• Tooth brushing must be associated with the number of meals; additionally, it is extremely important to use dental floss in order to prevent interproximal caries lesions (in between the teeth).• Have your teeth professionally cleaned every six months -or more frequently, if recommended by your dental surgeonto control plaque and prevent oral problems.

Periodontal problems
• Gingivitis is caused by the accumulation of bacterial plaque (food residue plus bacteria) in the gums, which can develop into periodontal disease.Do not forget to clean your teeth and gums by brushing for at least two minutes and flossing after each meal.• Periodically change your toothbrush (every 3 months), which must have soft bristles to prevent abrasion of the enamel and allow the gum to be cleaned without being hurt.• Wheat bran, brown rice and cereals are rich in iron and vitamin B and help keep gums healthy.

Dental erosion or wear
• Dental erosion or wear can lead to sensitivity, make your teeth yellowish and cause cracks; therefore, reduce your consumption of acidic foods and drinks (citrus fruits, vinegar and sodas).Use a straw to minimize the contact of these drinks with your teeth; never brush afterwards; you can rinse your mouth with water.• Chewing sugar-free gum before brushing stimulates salivation, which is thus recovered from excess acid.
• It is interesting to use a small amount of toothpaste, as it contains abrasive agents; add less than half of the product in relation to the length of the toothbrush head.• Never brush your teeth right after episodes of vomiting or reflux.Rinse your mouth with water if you are not at home, and use sugar-free gum to stimulate salivation.If you are at home, rinse your mouth with baking soda (1 teaspoon in half a glass of water) to alkalize your mouth.Wait half an hour to brush your teeth.• Ideally, meals should be eaten slowly; try chewing small pieces to prevent episodes of vomiting.
• It is important to remember that, by increasing the number of meals, the number of brushings must be increased too.

Halitosis (Bad breath)
• Halitosis (bad breath) can be caused by tobacco consumption, foods such as garlic, dry mouth, or coated tongue (with bacteria that cause bad breath).Therefore, brush your tongue to prevent bad breath, or even use a tongue scraper to clean it.

Bruxism
• Let us know if you are clenching or grinding your teeth because, in case of bruxism, you will be referred for appropriate treatment.PREVENTIVE ACTIONS CARRIED OUT BY THE PROFESSIONAL • Supervised hygiene guidance and bacterial plaque control, 6 and 12 months postoperatively, in order to prevent caries and periodontal disease.• Application of Clinpro White Varnish (3M ESPE) 5% fluoride varnish, full mouth, 6 and 12 months postoperatively, in order to prevent caries and tooth wear.

DISCUSSION
To date, we believe that this is the first randomized clinical trial to describe the impact of a health promotion program on the oral conditions of gastroplasty patients, with a 12-month longitudinal follow-up.
After gastroplasty (gastric sleeve and gastric bypass), oral health indicators, assessed after six and 12 months, showed better conditions for IG patients, with a significant reduction in oral health problems such as dental caries, periodontal disease, dental plaque and xerostomia, compared to the CG.
Corroborating a previous study 21 , which highlighted a high amount of bacterial plaque in gastroplasty patients, in this study, CG patients showed greater accumulation of plaque after six and 12 months.On the other hand, patients in the IG had a significant reduction in plaque index at both six and 12 months.
The present study is in line with research that also recommends periodic prophylaxis to help improve the oral hygiene status of patients undergoing bariatric surgery, which results in the prevention of oral diseases such as periodontitis, thus greatly improving the patient's quality of life 20 .
In a study by Elward et al. 5 , patients reported water intolerance, caused by gastric changes resulting from the surgery.To help with their intake and improve salivary flow, IG patients were advised to increase their water consumption by carrying a bottle of flavored water with them, in order to facilitate ingestion in small sips, in addition to using sugar-free gum in order to stimulate salivation, or using artificial saliva, when the patient had xerostomia 14 .
Although preoperatively most patients with xerostomia were part of the IG, possibly due to the use of xerostomia drugs 11 , this group achieved a significant increase in their average salivary flow in the 6-month postoperative period compared to the CG.After 12 months, corroborating the report by Quintella et al. 15 , no significant difference was observed between the groups, given that normalization of salivary flow was expected.
An increase in gingival bleeding, peaking at six months, is expected after bariatric surgery 4 ; in this study, while patients in the CG showed an increase in gingival bleeding six months after surgery, participants in the IG promotion program showed a significant reduction (p<0.0001), a fact that may be related to the oral health promotion actions that were developed in this group.In the 12-month postoperative period, there was also a significant difference between the groups for presence of dental calculus (p=0.002) and 4-5mm periodontal pocket (p<0.0001), with the results being favorable to the IG.
After six and 12 months, the incidence of caries was significantly lower among members of the IG compared to those in the CG, both in enamel and dentin.A previous study, in which there was no dental intervention, reported a significant increase in dental caries over time following gastroplasty 20 .
The bariatric diet, combined with inadequate oral hygiene, may result in an increase in carious lesions, because, with reduced gastric capacity, there is a medical recommendation to increase the frequency of food and liquid intake throughout the day 20 .Furthermore, hyposalivation, common in gastroplasty patients in the first months after surgery, is accompanied by an   Topical applications of fluoride varnish on all dental surfaces, every six months 24 , as well as educational-preventive guidance to improve hygiene, diet and salivary flow, had good results, such as the significant prevention of changes in enamel and dentin, and of tooth wear, in the two assessment periods (six and 12 months) of this study.The effectiveness of the product is due to its action in preventing and remineralizing carious lesions, in addition to preventing tooth erosion and cases of dentin hypersensitivity 19 .
A clinical trial conducted by Azevedo et al. 1 found a higher prevalence of tooth wear in patients after bariatric surgery; however, there was a lower occurrence of moderate tooth wear at six and 12 months for the IG, with a significant difference between the groups.
Corroborating a randomized clinical trial conducted by Scheerman et al. 17 , which reports that usual care combined with the use of a mobile application to send patients preventive messages provides oral health education, the findings of this study also showed the effectiveness of oral health education carried out by dental surgeons, based on theory and approach, with a significant improvement in patients' oral hygiene behavior 17 .
The patients in both groups had to be warned about the need for extractions, which could harm their recovery after gastroplasty if not performed, this being a possible limitation for the study, given that tooth losses were recorded also in the IG.Furthermore, not all patients returned to the clinic until the end of the research, since, if they felt well, they did not return to the multidisciplinary team appointments, which reduced the sample size in the second and third assessments (six and 12 months after surgery).
The educational-preventive care protocol narrated and evaluated in this trial proved to be effective in promoting the oral health of bariatric patients, preventing the impact of bariatric surgery on oral health in the IG, being significant for: salivary flow and gingival bleeding at six months, with significant results six and 12 months after surgery; changes in enamel and dentin, dental calculus and 4-5mm periodontal pocket, a reduction in the bacterial plaque index, in addition to less tooth wear rated as moderate.
Further research, with a longer follow-up period, is necessary in order to assess the greater benefits that the oral health promotion program can provide, over time, to gastroplasty patients.

CONCLUSIONS
The oral health promotion program had a positive impact on the prevention of dental caries, periodontal disease, xerostomia, dental erosion and plaque accumulation in gastroplasty patients, which reinforces the importance of including dental surgeons in the multidisciplinary teams that assist them.

Figure 1 -
Figure 1 -Protocol for promoting the oral health of bariatric patients.

Table 2 -
Average number of sextants affected by periodontal problems measured by the community periodontal index, in accordance with the groups and assessment periods.

Table 3 -
Mean and standard deviation of the International Caries Detection and Assessment System (ICDAS) index criteria, in accordance with the groups and assessment periods.

Table 4 -
Mean and standard deviation of the Dental Wear Index (DWI) criteria, in accordance with the groups and assessment periods. in cariogenic microorganisms, such as Lactobacillus and Streptococcus mutans, increasing the risk of caries, especially in the first six months 7 .